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Chronic disease management guidelines for CKD


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Chronic disease management guidelines for CKD

  1. 1. Sussex CKD Guidelines November 2009 These guidelines are based on NICE CKD guidelines (Sept 2008) for use in primary and secondary care in East and West Sussex and Brighton and Hove. Prepared by, and correspondence to: Dr Lawrence Goldberg, Consultant Nephrologist, Sussex Kidney Unit, Royal Sussex County Hospital, Brighton BN2 5BE. Contents Which groups of patients should be routinely tested for CKD? Assessing the severity of CKD Measuring the eGFR Assessing the change in eGFR over time CKD staging system Measuring and defining proteinuria and albuminuria Who needs a renal ultrasound? Referral criteria What information to include in a CKD referral letter Management of CKD and its complications Blood pressure targets Blood pressure treatment ACE inhibitors/ARBs in patients with CKD Reducing cardiovascular risk (statins, aspirin) Testing for anaemia in CKD Testing bone biochemistry in CKD (calcium, phosphate, PTH) Medications: general advice Haematuria investigation and referral algorithm 1
  2. 2. Which groups of patients should be offered testing for CKD? Patients with any of the following risk factors: • Diabetes • Hypertension • Cardiovascular disease (ischaemic heart disease, chronic heart failure, peripheral vascular disease and cerebral vascular disease) • Structural renal tract disease, renal calculi or prostatic hypertrophy • Opportunistic discovery of haematuria or proteinuria • Family history of stage 5 CKD (renal transplant, dialysis) or hereditary kidney disease (e.g. polycystic kidney disease) • Multisystem diseases with potential kidney involvement (e.g.,SLE) • Long term treatment with drugs which may cause chronic kidney damage (e.g. lithium, ciclosporin, NSAIDs) 2
  3. 3. Assessing the severity of CKD 1. GFR testing and assessment a) Measuring the eGFR Ideally measure eGFR when the patient has not eaten meat earlier that day. If the eGFR is <60 mls/min for the first time, repeat within 2 weeks to confirm, and to exclude an acute and rapidly progressive deterioration. Note that whilst the QoF definition of CKD (stage 3 or higher) is two eGFRs <60 over at least a 3 month period, the clinical definition would be two readings <60 over any time period without an acute cause. Interpret the eGFR according to the patient: • People with large muscle mass have a higher baseline creatinine production and therefore higher blood creatinine level, which will calculate to a lower eGFR. Therefore their eGFR will be lower than their true GFR, i.e. their kidney function will be under-estimated. • People with low muscle mass will produce less creatinine and therefore generate a lower blood creatinine level, which calculates to a higher eGFR. Therefore their eGFR will be higher than their true GFR, i.e. their kidney function will be an over-estimate. • If the person is of African-Caribbean or African ethnicity, multiply the reported eGFR by 1.21. • The eGFR as currently calculated is not validated for use in children, or in acute kidney injury (acute renal failure) b) Assessing the change in eGFR over time In many patients, the eGFR, even if low, is stable, and such patients are unlikely to develop progressive or end stage renal disease. To establish stability, it is essential to know serial eGFRs/plasma creatinine results over time (at least three months). N.B. rapid deterioration within three months without an identifiable cause (e.g. NSAIDs, over-diuresis) indicates acute rather than chronic kidney disease, and requires an urgent diagnosis with or without referral: this is outside of the scope of these CKD guidelines. c) The NICE definition of progressive CKD: • eGFR decline by more than 5 ml/min within one year (without identifiable and readily reversible cause) OR • eGFR decline by more than 10 ml/min within five years (without identifiable and readily reversible cause) d) CKD Staging system Stage eGFR Description (ml/min/1.73m2) 1/2* ≥ 60 Normal or increased GFR, with other evidence of kidney damage 3A 45–59 Moderate decrease in GFR with or without other evidence of kidney damage 3B 30–44 3
  4. 4. 4 15–29 Severe decrease in GFR with or without other evidence of kidney damage 5 < 15 Established renal failure • There is no meaningful distinction between stages 1 and 2. N.B. Use the suffix ‘p’ if the patient has significant proteinuria (ACR>30 or PCR>50) E.g if the eGFR is 40 and the PCR is 60, that is CKD stage 3Bp. 4
  5. 5. 2. Measuring and defining proteinuria and albuminuria • Proteinuria or albuminuria should be measured using either a protein:creatinine ratio (PCR) or an albumin: creatinine ratio (ACR) on a random (spot) urine sample (in to a plain universal collection bottle). 24 hour urine collections are NOT required. • Dipstick testing for proteinuria is unreliable, and should not replace PCR or ACR testing in the diagnosis of CKD. A negative dipstick for protein does not in fact reliably exclude significant proteinuria. • The ACR or PCR is reported as mg/mmol. To understand how this ratio relates to the actual amount of protein excretion, multiply the result x10 gives an approximation to the 24 hour excretion in mg/day. E.g. a PCR of 70mg/mmol equates to an excretion of 700mg (0.7g) per day. An ACR of 5.2 equates to 52mg/day excretion of albumin. • If or when a first abnormal result is obtained, it should be repeated on an early morning sample to confirm. (i) Patients without diabetes Significant levels of proteinuria in non-diabetics in the published literature is based on total urinary protein excretion, rather than the more specific measure of albumin excretion. However NICE advocates testing the ACR in preference to the PCR where available, and if considered economic. Currently the PCR test is cheaper, and better correlated with renal outcomes, and therefore the PCR is advocated in preference by the Sussex nephrologists, though an ACR would be acceptable. Note that this local recommendation may change in light of further published evidence of the benefit of ACR testing in non-diabetics. Definition of significant levels of protein excretion in patients without diabetes PCR ≥50mg/mmol or ACR ≥30mg/mmol (ii) Patients with diabetes Measure the ACR at diagnosis of diabetes, and then at least annually. Definition based on NICE and other national diabetes guidelines. Definition of significant albuminuria in presence of diabetes Women ACR >3.5mg/mmol Men ACR >2.5mg/mmol Who needs a renal ultrasound? A renal USS can be arranged before or at referral by the referring clinician, or by the renal specialist on receipt of the referral. Note that it will often be more convenient for a scan to be arranged by the referrer (rather than the renal unit) and done locally for patients not in the BSUH (Brighton or mid- Sussex) area, as long as it is carried out before the patient is first seen in the specialist clinic. Offer a renal ultrasound to all people with CKD who: – have stage 4 or 5 CKD (eGFR <30) – have progressive CKD (eGFR decline of >5 within 1 year or >10 within 5 years) – have visible, or persistent non-visible (microscopic) haematuria – have symptoms of urinary tract/bladder outflow obstruction 5 – have a family history of polycystic kidney disease and are aged over 20
  6. 6. N.B. Advise people with a family history of inherited kidney disease about the implications of an abnormal result before arranging the scan. 6
  7. 7. Referral Criteria Take into account the individual’s wishes and co-morbidities when considering referral. It may not be necessary for a person with CKD who meets these criteria to see a specialist in person, and specialist advice may be all that is required, depending on the individual case. People with CKD in the following groups should normally be referred for specialist assessment: A) All people (regardless of diabetes) • Stage 4 or 5 CKD (eGFR <30) • eGFR decline of >5 ml/min in 1 year, or >10 ml/min within 5 years, in the absence of a clear and reversible explanation (e.g. newly added ACEIs/AIIRBs, NSAIDs, over-diuresis, bladder outflow obstruction*) . NB abnormal results that might trigger a referral should be repeated to confirm before making referral. • Proteinuria (ACR ≥30 or PCR ≥50 mg/mmol) together with haematuria • Hypertension with eGFR<60, that remains poorly controlled despite the use of at least four antihypertensive drugs at therapeutic doses (hypertension without CKD should be referred to the hypertension service) • People with, or suspected of having, rare or genetic causes of CKD • Suspected renal artery stenosis. * People with symptoms or features of renal outflow obstruction with a reduced eGFR should have a kidneys and bladder USS scan and referral to urology in the first instance if hydronephrosis is detected, unless urgent medical intervention is required. B) People without diabetes only • Heavy proteinuria: ACR ≥ 70 mg/mmol or PCR ≥ 100 mg/mmol (regardless of haematuria). C) People with diabetes only Proteinuria without haematuria is usually due to diabetic nephropathy, and does not warrant a referral unless the criteria in A) above are met (co-existent haematuria, nephrotic syndrome or rapidly deteriorating GFR. Patients with diabetic nephropathy need excellent control of BP and blood glucose levels which should happen within primary care and where necessary a specialist diabetic clinic. D) Haematuria Patients with haematuria should in most cases be referred direct to the urological service. The subsequent need for a nephrology referral depends on the presence of significant proteinuria (PCR >50 or ACR >30), or deteriorating renal function (see above). The Renal Association and British Association of Urological Surgeons have produced guidelines on the assessment and management of haematuria, which can be found at %20Haematuria%20consensus%20guidelines%20July%202008.pdf, or in the associated BMJ Clinical Review (Assessment and management of non-visible haematuria in primary care, Kelly JD, Fawcett DP, Goldberg LC BMJ 2009; 338:a3021). The algorithm for investigation and referral of these haematuria from these guidelines is reproduced at the end of this document at Haematuria investigation and referral algorithm. 7
  8. 8. What information to include in a nephrology referral • Trend in renal function (plasma creatinine/eGFR over time). This is essential information to determine acute, chronic or progressive renal dysfunction. A single blood result is not sufficient. • Result of PCR or ACR • Full list of patient’s known diagnoses • Full list of current medications including start dates of drugs which may alter creatinine (or eGFR), especially ACE inhibitors, AII RBs, diuretics, NSAIDs, cimetidine • If hypertensive, a list of any known patient intolerances to previously tried anti-hypertensives Management post-referral Once a referral has been made, the patient has received a specialist opinion, and a plan jointly agreed, consider routine follow-up at the person’s GP surgery rather than in a specialist clinic. If care is transferred back to primary care the specialist clinic should recommend a management plan, and specify the criteria for future re-referral. 8
  9. 9. Management of CKD and its complications A. Blood pressure targets in CKD Target blood pressure is determined by a) the presence or absence of diabetes, and b) the degree of proteinuria or albuminuria. Also note that there is a target systolic BP range, rather than a simple upper limit, with the aim of avoiding excessively low treated blood pressures (which in patients with CKD are associated with worse outcomes). (i) Blood pressure targets in patients WITHOUT diabetes Proteinuria eGFR BP Target Systolic Diastolic ACR≥70 or PCR≥100 Any 120-129 <80 ACR<70 or PCR<100 <60 120-139 <90 (ii) Blood pressure targets in patients WITH diabetes and CKD Consistent with NICE Type II diabetes guidelines (2008) and NICE Type I diabetes guidelines (2004) Clinical feature(s) BP Target Systolic Diastolic eGFR<60 OR microalbuminuria1 (or retinopathy or pre- 120-129 <80 existing atherosclerotic disease) 1 ACR >2.5 (men) or >3.5 (women) 9
  10. 10. B. Blood pressure treatment Initial treatment is primarily guided by the presence of significant proteinuria (non-diabetics) or microalbuminuria (diabetics). If present, ACE inhibitors (or AII blockers if intolerant) should normally be offered as first line treatment. Diabetes present? Proteinuria First line treatment No ACR<30 or PCR<50 Treat as per NICE hypertension guidelines (based on age and ethnicity) No ACR≥30 or PCR≥50 ACEI (or ARB if intolerant) Yes Microalbuminuria absent Follow diabetic guidelines Yes Microalbuminuria present ACEI (or ARB if intolerant) (i). Use of ACIs/ARBs in patients with CKD • Check plasma potassium and creatinine/eGFR before and 1-2 weeks after starting, and after each dose increase • If tolerated, increase ACEI/ARB to maximum therapeutic dose before using a second or subsequent antihypertensive (ii) Change in renal function with ACEIs/ARBs • eGFR falls of up to 25% (or plasma creatinine rises of up to 30% if the eGFR is >60) do NOT indicate underlying renal artery stenosis, and in general should NOT precipitate the stopping of these medications. If there has been a noticeable change within this range, it is appropriate to simply re-check the renal function after a further one-two weeks. • If the eGFR has fallen by ≥25% (or plasma creatinine has risen by ≥30%), first consider other causes, e.g. over-diuresis or concurrent NSAID use. If no other apparent cause, stop the ACEI/ARB or reduce to previous tolerated dose, and use or add ann alternative anti-hypertensive. (ii) Potassium levels and ACEIs/ARBs • Do not start an ACEI/ARB if the baseline plasma potassium is above the laboratory’s normal range. Look for other factors causing hyperkalaemia, especially potassium-sparing diuretics (watching out for combination diuretics), and stop such medications if appropriate and re-check the potassium level. Note that beta blockers can also raise the plasma potassium. • If the potassium level rises to between 5.0 and 6.0 mmol/L after starting or increasing the dose of and ACE/ARB, stop any potassium sparing diuretic, and re-check. A low potassium diet should also be considered if the potassium remains in this range, and it is considered important to continue with the ACE (e.g. significant proteinuria) • If the plasma potassium rises to ≥6.0mmol/L on an ACEI/ARB, and other reversible factors have been excluded, stop the ACEI/ARB, or reduce to previously tolerated dose. 10
  11. 11. Reducing cardiovascular risk (i) Blood pressure: treat to target (see above) (ii) Statins: a) Primary prevention. Use in same way as for patients without CKD b) Secondary prevention. Offer to patients irrespective of baseline lipid levels (as for patients without CKD) (iii) Aspirin: Use for secondary prevention as for non-CKD patients (if no usual contra-indications). No indication for primary prevention based on the patient’s CKD status Testing for anaemia in CKD • Check the haemoglobin when the eGFR is <45ml/min (i.e. CKD stages 3b, 4 and 5) as renal anaemia (due to erythropoietin deficiency) becomes more common with this degree of renal impairment. • Notethat other causes of anaemia should be actively considered first as for any patient without renal impairment, and anaemia in a patient with CKD should NOT be assumed to be due to CKD until other causes have been excluded. • An Hb <10.5g/dL, if considered to be due to CKD (eGFR<45 and other causes excluded), may warrant treatment with an ‘erythropoiesis stimulating agent’ (ESA) and referral to the renal specialist service should be considered, particularly if symptomatic. Testing for and treating abnormalities of bone metabolism • Thereis no indication for the routine measurement of calcium, phosphate and parathyroid hormone (PTH) if the eGFR is ≥30ml/min (CKD stages 1, 2, 3a and 3b). • Testing in stages 4 and 5 CKD would usually be undertaken by the specialist service following referral of these patients (see referral criteria above). If vitamin D supplementation is indicated: CKD stages 1-3b (eGFR ≥30): use colecalciferol or ergocalciferol CKD stages 4 and 5 (eGFR <30): Use alfacalcidol or calcitriol (on specialist advice), and monitor plasma calcium following initiation or dose increases) General advice on medications • NSAIDs: avoid, or use with caution, in patients with eGFR<60. If being taken regularly, check renal function intermittently. • Potassium sparing diuretics: avoid unless patient known to be hypokalaemic, or required for management of heart or liver failure or other specialist conditions (ensuring the potassium level is checked from time to time) • Any drug: consider the need for dose adjustments for impaired renal function (refer to BNF, appendix 3) 11
  12. 12. Decision Algorithm for the Investigation and Referral of Haematuria Joint British Association of Urological Surgeons/Renal Association Guidelines 2008 12